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Complaint Investigation

Evergreen Post Acute

April 17, 2025 · Smyrna, DE · 3034 South Dupont Blvd
Citations 3
CMS Rating 3/5
Beds 151
Provider ID 085020
Healthcare Facility
Evergreen Post Acute
Smyrna, DE  ·  View full profile →
Inspection Summary

EVERGREEN POST ACUTE in SMYRNA, DE — inspection on April 17, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF677
Minimal harm or included assist with daily hygiene, grooming, dressing, oral care, and eating as needed. Some and required substantial maximum assistance for personal hygiene and grooming. affected

Review of R130's clincial record revealed:

3/7/25 - R130 was admitted to the facility.

085020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085020 B.

Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

The facility failed to initiate EBP for R14 until eight months (from 4/1/24 to 11/22/24) after the new guidelines were mandated.

4/16/25 - 12:01 PM -

During an interview, E2 (DON) confirmed that R14 has had a colostomy since he has been in the facility.

2.

Review of R639's clinical record revealed:

6/21/24 - R639 was admitted to the facility with diagnoses including but not limited to, chronic obstructive pulmonary disease.

085020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085020 B.

Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977

7/30/24 - R112 was admitted to the facility.

8/27/24 3:12 PM - A physician's order documented that R112 was on contact isolation due to scabies for fourteen days.

11/9/24 - A physicians order was written for R112 consult to dermatology related to scabies.

11/13/24 - A specialist physician's (dermatologist) progress note documented that R112 was not contagious and to remove isolation precautions.

4/15/25 10:30 AM - An interview with C2 (NP) and C5 (NP) confirmed that R112 was on contact precautions from 8/27/24 to 11/13/24.

There was a ten week delay in consulting the dermatologist resulting in R112 being in isolation for 78 days.

47621

2. R644's clinical record revealed:

Cross refer

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SMYRNA, DE, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EVERGREEN POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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